Post-Traumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the personís daily life.
PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the personís ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.

***** UNDERSTANDING PTSD *****

PTSD is not a new disorder. There are written accounts of similar symptoms that go back to ancient times, and there is clear documentation in the historical medical literature starting with the Civil War, where a PTSD-like disorder was known as "Da Costaís Syndrome." There are particularly good descriptions of post-traumatic stress symptoms in the medical literature on combat veterans of World War II and on Holocaust survivors.
Careful research and documentation of PTSD began in earnest after the Vietnam War. The National Vietnam Veterans Study estimated in 1988 that the prevalence of PTSD in that group was 15.2% at that time, and that 30% had experienced the disorder at some point since returning from Vietnam.
PTSD has subsequently been observed in all veteran populations that have been studied, including World War II, Korean conflict, and Persian Gulf, and in United Nations peacekeeping forces deployed to other war zones around the world. PTSD also appears in military veterans in other countries with remarkably similar findings ó that is, Australian Vietnam veterans experience much the same symptoms as American Vietnam veterans.
PTSD is not only a problem for veterans, however. Although there are unique cultural- and gender-based aspects to the disorder, it occurs in both men and women, adults and children, Western and non-Western cultural groups, and all socioeconomic strata. A national study of American civilians conducted in 1995 estimated that the lifetime prevalence of PTSD was 5% in men and 10% in women.

***** HOW DOES PTSD DEVELOPE *****

Most people who are exposed to a traumatic, stressful event experience some of the symptoms of PTSD in the days and weeks following exposure. Available data suggest that about 8% of men and 20% of women go on to develop PTSD, and roughly 30% of these individuals develop a chronic form that persists throughout their lifetimes.
The course of chronic PTSD usually involves periods of symptom increase followed by remission or decrease, although for some individuals symptoms may be unremitting and severe. Some older veterans who report a lifetime of only mild symptoms have experienced significant increases following retirement, severe medical illness in themselves or their spouses, or reminders of their military service such as reunions or media broadcasts of the anniversaries of war events.

***** HOW IS PTSD ASSESSED *****

In recent years a great deal of research has been aimed at development and testing of reliable assessment tools. It is generally thought that the best way to diagnose PTSD ó or any psychiatric disorder, for that matter ó is to combine findings from structured interviews and questionnaires with physiological assessments. A multi-method approach is especially helpful to address concerns that some patients might be either denying or exaggerating their symptoms.

***** HOW COMMON IS PTSD *****

An estimated 7.8 percent of Americans will experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to have PTSD. About 3.6 percent of U.S. adults ages 18 to 54 (5.2 million people) have PTSD during the course of a given year. This represents a small proportion of those who have experienced a traumatic event at some point in their lives, for 60.7% of men and 51.2% of women reported at least one traumatic event. The traumatic events most often associated with PTSD are: for men: rape, combat exposure, childhood neglect, and childhood physical abuse. For women: rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.
About 30 percent of the men and women who have spent time in war zones experience PTSD. An additional 20 to 25 percent have had partial PTSD at some point in their lives. Thus more than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced "clinically serious stress reaction symptoms." PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as 8 percent.

***** WHO IS MOST LIKELY TO DEVELOPE PTSD *****

1. Those who experience greater stressor magnitude and intensity, unpredictability, uncontrollability , sexual (as opposed to nonsexual) victimization, real or perceived responsibility, and betrayal.
2. Those with prior vulnerability factors such as genetics, early age of onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events.
3. Those who report greater perceived threat or danger, suffering or being upset, terror, and horror or fear.
4. Those with a social environment which produces shame, guilt, stigmatization, or self-hatred.

***** WHAT ARE THE CONSEQUENCES ASSOCIATED WITH PTSD *****

PTSD is associated with a number of distinctive neurobiological and physiological changes. PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems, such as altered brainwave activity, decreased volume of the hippocampus, and abnormal activation of the amygdala. Both of these brain structures are involved in the processing and integration of memory . The amygdala has also been found to be involved in coordinating the body's fear response.
Psychophysiological alterations associated with PTSD include hyperarousal of the sympathetic nervous system, increased sensitivity of the startle reflex, and sleep abnormalities.
People with PTSD tend to have abnormal levels of key hormones involved in response to stress. Thyroid function seems to be enhanced in people with PTSD. Some studies have shown that cortisol levels are lower than normal and epinephrine and norepinephrine are higher than normal. People with PTSD also continue to produce higher than normal levels of natural opiates after the trauma has passed. An important finding is that the neurohormonal changes seen in PTSD are distinct from, and actually opposite to, those seen in major depression; also, the distinctive profile associated with PTSD is seen in individuals who have both PTSD and depression.
PTSD is associated with increased likelihood of co-occurring psychiatric disorders. In a large-scale study, 88 percent of men and 79 percent of women with PTSD met criteria for another psychiatric disorder. The co-occurring disorders most prevalent for men with PTSD were alcohol abuse or dependence (51.9 percent), major depressive episode (47.9 percent), conduct disorder (43.3 percent), and drug abuse and dependence (34.5 percent). The disorders most frequently comorbid with PTSD among women were major depressive disorder (48.5 percent), simple phobia (29 percent), social phobia (28.4 percent) and alcohol abuse/dependence (27.9 percent).
PTSD also makes a significant impact on psychosocial functioning, independent of comorbid conditions. For instance, Vietnam veterans with PTSD were found to have profound and pervasive problems in their daily lives. This included problems in family and other interpersonal relationships, employment, and involvement with the criminal justice system.
Headaches, gastrointestinal complaints, immune system problems, dizziness, chest pain, or discomfort in other parts of the body are common in people with PTSD. Often, medical doctors treat the symptoms without being aware that they stem from PTSD.

***** WHAT IS THE COURSE OF PTSD *****

Most people who are exposed to a traumatic stressor experience some of the symptoms of PTSD in the days and weeks following exposure. Available data suggest that among individuals who go on to develop PTSD, roughly 30 percent develop a chronic form that persists throughout an individualís lifetime. The course of chronic PTSD usually has periods of symptom exacerbation and remission or decrease, although for some individuals symptoms may persist at an unremitting, severe level. Some older veterans who report a lifetime of no or only mild symptoms have experienced symptom exacerbations following retirement, severe medical illness in themselves or their spouses, or exposure to reminders of their military service (such as reunions or media broadcasts of the anniversaries of war events).

***** HOW IS PTSD TREATED *****

PTSD is treated by a variety of forms of psychotherapy and drug therapy. There is no definitive treatment, and no cure, but some treatments appear to be quite promising, especially cognitive-behavioral therapy, group therapy, and exposure therapy, in which the patient repeatedly relives the frightening experience under controlled conditions to help him or her work throughout the trauma. Studies have also shown that medications help ease associated symptoms of depression and anxiety and help ease sleep. The most widely-used drug treatments for PTSD are the selective serotonin reuptake inhibitors, such as Prozac and Zoloft. At present, cognitive-behavioral therapy appears to be somewhat more effective than drug therapy, but it would be premature to conclude that drug therapy is less effective overall since drug trials for PTSD are at a very stage. Drug therapy definitely appears to be highly effective for some individuals and is helpful for many more. Also, the recent findings on the biological changes associated with PTSD have spurred new research into drugs that target these biological changes, which may lead to much increased efficacy.

***** TREATMENT OF PTSD *****

** A National Center for PTSD Fact Sheet **

* Introduction *

This fact sheet describes elements common to many treatment modalities for PTSD, including education, exposure, exploration of feelings and beliefs, and coping skills training. Additionally, the most common treatment modalities are discussed, including cognitive-behavioral treatment, pharmacotherapy, EMDR, group treatment, and psychodynamic treatment.

** Common Components of PTSD Treatment **

Treatment for PTSD typically begins with a detailed evaluation, and development of a treatment plan that meets the unique needs of the survivor. Generally, PTSD-specific-treatment is begun only when the survivor is safely removed from a crisis situation. For instance, if currently exposed to trauma (such as by ongoing domestic or community violence, abuse, or homelessness), severely depressed or suicidal, experiencing extreme panic or disorganized thinking, or in need of drug or alcohol detoxification, addressing these crisis problems becomes part of the first treatment phase.
Educating trauma survivors and their families about how persons get PTSD, how PTSD affects survivors and their loved ones, and other problems that commonly come along with PTSD symptoms. Understanding that PTSD is a medically recognized anxiety disorder that occurs in normal individuals under extremely stressful conditions is essential for effective treatment.
Exposure to the event via imagery allows the survivor to reexperience the event in a safe, controlled environment, while also carefully examining their reactions and beliefs in relation to that event.
Examining and resolving strong feelings such as anger, shame, or guilt, which are common among survivors of trauma.
Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but become manageable with new coping skills.

** Therapeutic Approaches Commonly Used to Treat PTSD **

Cognitive-behavioral therapy (CBT) involves working with cognitions to change emotions, thoughts, and behaviors. Exposure therapy, is one form of CBT unique to trauma treatment which uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context, to help the survivor face and gain control of the fear and distress that was overwhelming in the trauma. In some cases, trauma memories or reminders can be confronted all at once ("flooding"). For other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stresses or by taking the trauma one piece at a time ("desensitization").
Along with exposure, CBT for trauma includes learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts ("cognitive restructuring"), managing anger, preparing for stress reactions ("stress inoculation"), handling future trauma symptoms, as well as addressing urges to use alcohol or drugs when they occur ("relapse prevention"), and communicating and relating effectively with people ("social skills" or marital therapy).
Pharmacotherapy (medication) can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases may help relieve the distress and emotional numbness caused by trauma memories. Several kinds of antidepressant drugs have achieved improvement in most (but not all) clinical trials, and some other classes of drugs have shown promise. At this time no particular drug has emerged as a definitive treatment for PTSD, although medication is clearly useful for the symptom relief that makes it possible for survivors to participate in psychotherapy.
Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new treatment of traumatic memories which involves elements of exposure therapy and cognitive behavioral therapy, combined with techniques (eye movements, hand taps, sounds) which create an alteration of attention back and forth across the person's midline. While the theory and research are still evolving with this form of treatment, there is some evidence that the therapeutic element unique to EMDR, attentional alteration, may facilitate accessing and processing traumatic material.
Group treatment is often an ideal therapeutic setting because trauma survivors are able to risk sharing traumatic material with the safety, cohesion, and empathy provided by other survivors. As group members achieve greater understanding and resolution of their trauma, they often feel more confident and able to trust. As they discuss and share coping of trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one's story (the "trauma narrative") and directly facing the grief, anxiety, and guilt related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of their lives.
Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event, particularly as they relate to early life experiences. Through the retelling of the traumatic event to a calm, empathic, compassionate and non-judgmental therapist, the survivor achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and more successfully deals with the intense emotions that emerge during therapy. The therapist helps the survivor identify current life situations that set off traumatic memories and worsen PTSD symptoms.

***** PSYCHIATRIC DISORDERS COMMONLY CO-OCCURRING WITH PTSD *****

Psychiatric disorders commonly co-occurring with PTSD include: depression, alcohol/substance abuse, panic disorder, and other anxiety disorders. Although crises that threaten the safety of the survivor or others must be addressed first, the best treatment results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol/substance abuse.

***** COMPLEX PTSD *****

Complex PTSD (sometimes called "Disorder of Extreme Stress") is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. Developmental research is revealing that many brain and hormonal changes may occur as a result of early, prolonged trauma, and contribute to difficulties with memory, learning, and regulating impulses and emotions. Combined with a disruptive, abusive home environment which does not foster healthy interaction, these brain and hormonal changes may contribute to severe behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), emotional regulation difficulties (such as intense rage, depression, or panic) and mental difficulties (such as extremely scattered thoughts, dissociation, and amnesia). As adults, these individuals often are diagnosed with depressive disorders, personality disorders or dissociative disorders. Treatment often takes much longer, may progress at a much slower rate, and requires a sensitive and structured treatment program delivered by a trauma specialist.

***** PTSD AND THE FAMILY *****

** A National Center for PTSD Fact Sheet **

** Can PTSD in one family member affect the entire family **

The entire family is profoundly affected when any family member experiences psychological trauma and suffers posttraumatic stress disorder (PTSD). Some traumas are directly experienced by only one family member, but other family members may experience shock, fear, anger, and pain in their own unique ways simply because they care about and are connected to the survivor.
Living with an individual who has PTSD does not automatically cause PTSD, but it can produce "vicarious" or "secondary" traumatization. Whether family members live together or apart, are in contact often or rarely, and feel close or distant emotionally from one another, PTSD affects each member of the family in several ways.

** How does PTSD affect Family Members **

* Emotional Reactions *

Family members may feel hurt, alienated, frustrated, or discouraged, if the survivor loses interest in family or intimate activities and is easily angered or emotionally isolated and detached.
Family memers often end up feeling angry or distant toward the survivor, especially if he or she seems unable to relax and be companionable without being irritable, tense, anxious, worried, distractible, or controlling, overprotective, and demanding.
Even if the trauma occurred decades ago, survivors may act -- and family members may feel -- as if the trauma never stops happening. They may feel as if they're living in a warzone or a disaster if the survivor is excessively on-guard, tense, or easily startled or enraged.

* Isolation/Avoidance *

Family members can find themselves avoiding activities or people and becoming isolated from each other and from friends outside the family. They may feel that they have no one to talk to, and that no one that can understand.

* Communication *

Family members may find it very difficult to have a cooperative discussion with the survivor about important plans and decisions for the future, because s/he feels there is no future to look forward to, because s/he has difficulty listening and concentrating without becoming distracted, tense, or anxious, or because s/he becomes angry and overly suspicious toward the family member or toward others (hypervigilant).
Family members may find it very difficult to discuss personal or family problems, because the survivor becomes either controlling, demanding, or overprotective, or unreasonably anxious and fearful about problems becoming terrible catastrophes.

* Parenting *

The person suffering from PTSD may become overinvolved with their children's lives due to feeling lonely and in need of some positive emotional feedback, or feeling that the partner can't be counted on as a reliable and responsible parent. For the survivor, this "discounting" of the their partner as a co-parent often is due to hypervigilance and guilt because of trauma experiences involving children.
The partner may feel s/he must be the sole caregiver to their children if the survivor is uninvolved with their children (often due to trauma-related anxiety or guilt) or is overly critical, angry, or even abusive.

* Sleep *

Partners may find their sleep disrupted by the trauma survivor's sleep problems (reluctance to sleep at night, restlessness while sleeping, severe nightmares, or episodes of violent "sleepwalking." Family members also often find themselves having terrifying nightmares, afraid to go to sleep, or difficulty getting a full and restful night's sleep, as if they are reliving the survivor's trauma in their own feelings and sleep.
Ordinary activities, such as going shopping or to a movie, or taking a drive in the car, may feel like reliving of past trauma when the survivor experiences trauma memories or flashbacks. The survivor may go into "survival mode" or on "automatic pilot," suddenly and without explanation shutting down emotionally, becoming pressured and angry, or going away abruptly and leaving family members feeling shocked, stranded, helpless, and worried.

* Abuse *

Trauma survivors with PTSD often struggle with intense anger or rage, and can have difficulty coping with an impulse to lash out verbally or physically -- especially if their trauma involved physical abuse or assault, war, domestic or community violence, or being humiliated, shamed and betrayed by people they needed to trust. Family members can feel frightened of and betrayed by the survivor, despite feeling love and concern.

* Addiction *

Addiction exposes family members to emotional, financial, and (less often, but not uncommonly) domestic violence problems. Survivors experiencing PTSD may seek relief and escape with alcohol or other drugs, or through addictive behaviors such as gambling, workaholism, overeating or refusing to eat (bulimia and anorexia). Addictions offer false hope to the survivor, by seeming to help for a short time but then making PTSD's symptoms of fear, anxiety, tension, anger, and emotional numbness far worse. Addictions may be very obvious, such as when binge drinking or daily use of drugs occurs. However they may involve lighter or less frequent episodes of "using" that are a problem because the survivor is dependent ("hooked") on the habit and can't cope without it.

* Suicide *

When suicide is a danger, family members face these unavoidable strains: worry ("How can I know is suicide is going to happen, and what can I do to prevent it?"), guilt ("Am I doing something to make her/him feel so terrible, and should I be doing something to make her/him feel better?"), grief ("I have to prepare myself every day for losing her/him. In many ways I feel and have to live my life as if s/he's already gone."), and anger ("How can s/he be so selfish and uncaring?"). Trauma survivors with PTSD are more prone to contemplate and attempt suicide than similar people who have not experienced trauma or are not suffering from PTSD. For the family there is good and bad news in this respect. The good news is that very few trauma survivors, even those with PTSD, actually attempt or complete suicide. The bad news is that family members with a loved with PTSD often must deal with the survivor?s feeling sufficiently discouraged, depressed, and even self- blame and self-loathing to seriously and frequently contemplate suicide.

***** What can families of trauma survivors with PTSD do *****

What can families of trauma survivors with PTSD do to care for themselves and the survivor? Continue to learn more about PTSD by attending classes, viewing films, or reading books. Encourage, but don't pressure, the survivor to seek counseling from a PTSD specialist. Seek personal, child, couples, or family counseling if troubled by "secondary" trauma reactions such as anxiety, fears, anger, addiction, or problems in school, work, or intimacy. Take classes on stress and anger management, couples communication, or parenting. Stay involved in positive relationships, in productive work and education, and with enjoyable pasttimes.
If physical (domestic) violence actually is occurring, family members such as spouses, children, or elders must be protected from harm.